Diagnostic Errors in Patients With Rashes, Moles, and Other Skin Findings

Graeme M. Lipper, MD

Disclosures

September 06, 2017

Treated for Recurrent Cellulitis

A 72-year-old Hispanic woman has been admitted to the hospital three times over the past 2 months for recurrent bilateral lower-extremity cellulitis. She now presents to the emergency department complaining of worsening bilateral lower-extremity swelling with redness, burning, and itching of 5 days' duration. She is afebrile but complains of pain and throbbing, especially when standing. During each of her three previous inpatient stays, her skin improved with intravenous antibiotics (one course of cephalosporin, one course of vancomycin) and topical emollient application; however, she reports that her symptoms always worsen within days of discharge.

Examination reveals an afebrile, morbidly obese woman with 2+ bilateral lower-extremity pitting edemas below the knees. In addition to prominent bilateral lower-extremity varicosities, her skin shows diffuse erythema with lichenification and scaling, scattered excoriations, rust-colored macular dyschromia, and coalescent ivory-white atrophic plaques on her medial and lateral ankles consistent with atrophie blanche. A review of her laboratory test results shows a normal complete blood count with differential, elevated erythrocyte sedimentation rate and C-reactive protein level and elevated fasting glucose and HbA1c levels consistent with her history of diabetes mellitus (Figure 10).

Figure 10. Lower-limb cellulitis. Image from Medscape Reference.

What is the medical error?

Cellulitis vs Stasis Dermatitis

This patient has several risk factors for lower-limb cellulitis, including advanced age, obesity, venous insufficiency, and diabetes mellitus. However, her presentation raises several red flags that cellulitis is not an adequate clinical explanation. Cellulitis is rarely bilateral and should be associated with additional signs (fever, chills, malaise, warmth, and severe tenderness on palpation, lymphangitic streaking) and laboratory abnormalities (leukocytosis) that are absent in this case.

Her history of venous insufficiency with chronic varicosities is highly suggestive of stasis dermatitis nodosum (Figure 11).[9,10]

Figure 11. A patient with severe stasis dermatitis. Image courtesy of Dr Gary White (regionalderm.com).

This chronic eczematous dermatitis of the lower legs and ankles features erythema, inflammatory papules, scaling, dermal sclerosis, and excoriations, sometimes complicated by ankle ulcers with necrotic bases. Management requires both acute treatment of flares and chronic management, with a combination of short-term topical corticosteroids to reduce inflammation, maintenance compression (stockings or lymphatic press), emollient application, and antibiotic treatment of secondary infections (most commonly caused by Staphylococcus aureus, both methicillin-sensitive and resistant).

This patient also reported using topical Neosporin as an emollient at home, raising the possibility of a superimposed allergic contact dermatitis. Other mimics of lower-limb cellulitis include thrombophlebitis, drug hypersensitivity reactions, eosinophilic cellulitis (Well's syndrome), and panniculitis such as erythema

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